Since 2010, the Affordable Care Act (ACA) has been rapidly changing the healthcare system in the United States. This transformation is occurring because of broadening healthcare insurance coverage,1 which in turn opens publicly and privately provided care to millions of Americans.

Expanding the insurance coverage base has also led to increasing access of primary care delivery through community pharmacies. By providing expanded primary care services, community pharmacies help meet the 2 significant goals of the ACA: (1) expanding care to the insured and uninsured, while (2) providing greater access to care.

Community Pharmacies and Walk-In Clinics

Community-based pharmacies in the United States began incorporating convenience clinics (ie, walk-in clinics located in stores, malls, and other retail settings) into their business models in 2000.2 They were developed to provide affordable, accessible, and quality medical care to patients. The goal was to reduce wait times, emergency department visits, and costs, while providing health and wellness solutions that could fulfill unmet needs of the US population.

These clinics have opened in national, regional, and local chains, supermarket- and store-based, as well as traditional, independent, stand-alone pharmacies.3 With 92% of Americans living within 1.6 miles of a pharmacy, and 67,000 community pharmacies, the growth of convenience clinics is estimated to reach 2700 by 2019.2 Currently, there are 13 billion annual visits—or 530 to 570 daily visits—to pharmacies.3 For many of these visits, patients come to pharmacies seeking advice and treatment for common illnesses, point-of-care testing, clinical chemistry and immunoassay laboratory testing, vaccinations, physical examinations, and wellness visits.2 These services are offered by nurse practitioners, physician assistants, and pharmacists under community-based physician oversight, and sanctioned by state regulations. It is estimated that total sales of these offerings will be approximately $500 million in 2019.2 The European Union has established this type of practice with lower costs and effective care.4 The relative success of these clinics suggests that patients are open to receiving more and different types of healthcare services through pharmacies.

Convenience clinics have not been immune to controversy. The American Academy of Family Physicians, American Medical Association, and American Academy of Pediatrics have raised the question of whether these clinics provide quality care.5 However, evidence to date suggests that the quality of care is comparable between convenience clinics and physician offices or urgent care clinics.6-8 In addition, people with low incomes have not used these clinics, continuing to favor emergency departments.4 Reimbursement rates in some states remain a barrier to the adoption of convenience clinics by pharmacy management. However, there remains a critical need to understand why people with low incomes do not use these clinics, and reimbursement systems that would allow these clinics to better serve this patient population.

We are quantitatively modeling the potential demand for a range of primary care services delivered through pharmacy-based convenience clinics throughout the United States, across urban, suburban, and rural communities. A preparatory and exploratory qualitative research phase was conducted through a series of interviews with patients, community pharmacists, and reimbursement decision makers across the United States. The aim was to gain their perspectives on consumer engagement with the primary care healthcare system, the role of the pharmacy profession in the provision of care services, and payers’ willingness to reimburse pharmacy-directed primary care services.

Methods

This study protocol was approved by the University of Utah Institutional Review Board, and conducted in accordance with the World Medical Association Declaration of Helsinki: Ethical Principles for Medical Research Involving Human Subjects.

Qualitative interviews were conducted with 3 key constituencies—consumers, community pharmacists, and payers (ie, reimbursement decision makers)—who were recruited by an independent market research agency from nationally representative panels of patients, healthcare professionals, and executives who pre-enrolled to participate in research studies, between April and June 2015.

All participating consumers (N = 19) were screened for age between 18 and 70 years, having filled ≥5 prescriptions in the past year at a community pharmacy (not solely mail order, hospital, or physician’s office), and to include a mix of ethnicities, employment status household incomes, insurance statuses, and urban/rural residences. Participating community pharmacists (N = 20) were screened to be from a mix of independent and chain pharmacies in rural, suburban, and urban pharmacy locations; there was a cap of a maximum of 4 participants who could be pharmacists-in-charge. Participating payers (N = 8) were screened to be heavily involved in decision-making of coverage/formulary policies in their organization surrounding medical services. Directors of claims or payers involved in actual management of the claim review process were excluded from the analysis.

Consumers and pharmacists were interviewed online via online bulletin board (OBB) methods. We have previously published work on a program of research using OBBs to interview panels of healthcare decision makers over the course of a year,9 and developed analytic approaches for the interpretation of verbatim data derived from such interviews.10 Respondents were invited to participate in a day-long interview process online. Each respondent engaged for approximately 2 hours on the OBB over the course of the day. Panel members logged on and participated in group interview questions—which facilitate cross-respondents, discussion—and follow-up individual querying by the moderator. This allows for discussion of any confidential concerns in a private window with the moderator. Interviews were moderated by independent professional market research moderators with direct patient and healthcare provider interviewing experience. Each panel ran from 6 am Pacific Standard Time through 10 pm Eastern Standard Time to allow for maximal participation across time zones and employment considerations. All respondents received industry-standard honoraria for their participation ($125 for patients, and $250 for pharmacists). The investigator teams observed the interviews and provided suggestions to the moderator for additional probes as required. It was important that the investigators did not directly interview respondents to avoid researcher-driven biases steering the respondents’ discussions.

Given the potential for commercially sensitive disclosures, payers were not interviewed in the group OBB format, but individually for 45 minutes over the phone, and received an industry-standard honoraria of $500. All interviews were transcribed and digitally recorded.

Results

Consumers’ Perspectives

Respondents had a mean age of 47 years (standard deviation [SD], 13 years); 3 were aged ≥65 years. The majority (11) were women, and 10 were white, with the others being black/African American (4), Hispanic (3), Asian or Pacific Islander (1), and Native American/Alaskan (1). Nine respondents lived in rural settings, 4 in a small town, 2 in a suburb, and 4 in a large city. The majority (15) had health insurance, and 9 had annual household incomes <$50,000. Eight respondents were working full- or part-time, 4 were not currently working, and the remainder were full-time homemakers (3), students (1), or retirees (3).

Overall, consumer perspectives indicated that they tended to hold onto the niche-like view of pharmacy’s role within healthcare. Their experiences centered on medication dispensing and advising, and, as such, they saw pharmacies as places to fill, refill, and manage prescriptions.

“I pick up and drop off prescriptions. Purchase things on sale as noted in their weekly flyer. When my grandkids are going to be around, I may go to pick up diapers there. It is also a convenient place for greeting cards.”

—Man, suburb

In addition, the pharmacy was considered by consumers to be a place of relaxation, and a final step when getting treatment for conditions. Interactions between consumers and pharmacists were usually brief. Few consumers reported any personal connection to a pharmacist. Nevertheless, many consumers had positive opinions of their pharmacist.

“I am always counseled by a pharmacist, whether I am picking up a new prescription or a refill. If [it is] a new prescription, he will tell me about the side effects, what to take with the prescription and what not to.”

—Woman, small city or town

Although preventive healthcare is part of many pharmacies’ service offerings across the United States, many consumers said their pharmacy did not have a role in their preventive healthcare, and most preferred to receive primary care through a physician office. Some consumers used and relied upon more preventive services than provided in the pharmacy setting. Vaccines were found to be the most used preventive health service at the pharmacy.

“They always make sure to call me when it is time for any of my shots including my Depo[-Provera; (medroxyprogesterone)], flu, and pneumonia [vaccines]. They work closely with my doctor to keep track of things such as times for mammograms and such as well.”

—Woman, rural

When presented with descriptions of additional preventive and primary care services that could be offered through the pharmacy, consumers were divided between those who are open to a broader array of services, and those who saw themselves as “traditionalists,” relatively uncomfortable with broad expansion. Of the 19 participants included in the analysis, 8 were pro-expansion, 8 were open to limited expansion, and 3 were against any change. Consumers who reported being more open to expansion recognized the value of additional services, including annual sports physicals, screening for illnesses such as influenza or group A Streptococcus, immunizations, basic wound care, blood glucose monitoring, and basic laboratory work (eg, chemistry, hematology, and urinalysis). Two-thirds of consumers were open to the idea of having physical examinations performed within the pharmacy setting. Minor illness, minor injury (particularly minor burns), and skin condition examinations had the highest appeal. For a small portion of consumers, greater integration of primary care within the pharmacy is something they hoped to see in the future.

“Honestly, and most likely not a mainstream opinion, I feel like adding more and more services at the pharmacy detracts from the purpose of the pharmacy. When the pharmacist and staff are involved in a lot of non-medication related things, it increases the risk of human error.”

—Woman, rural

A significant barrier to the provision of preventive and primary care services was privacy the consumers reported, including waiting areas and private clinic rooms, and the resulting need to renovate the physical space to incorporate private space for conducting primary care services. Other concerns shared by the consumers regarding the expansion of pharmacy services were staffing resources, lack of training for the patient-centric style of a nurse practitioner, physician assistant, or primary care provider.

“While some pharmacists exhibit empathy, others are just there to dispense drugs. Nurses are trained to be in tune with people—they deal with people daily, and not just in a retail environment. They are also trained to observe and report. The question must be asked as to whether the other roles pharmacists play will give them the time or the inclination to actively be involved with patients.”

—Man, suburb

Consumers reported being interested in more extensive pharmacy access in terms of hours and days per week. Ideally, they would like a 24-hour pharmacy, but most consumers were willing to compromise with allotted evening and weekend hours. If additional services are provided, they would minimally like the option to visit the pharmacy during evenings, and ≥1 days per weekend. A mixture of walk-in times and appointments would be appreciated by consumers. For walk-in service, consumers are, on average, comfortable with waiting 30 minutes. If an appointment is made, they would expect to be seen within 10 to 15 minutes of their appointment time.

“It’s vital; I have 4 kids and a hectic schedule—having 24-hour medical access would be a dream-come-true for parents and the chronically ill like myself.”

—Man, large city

Regarding financial accessibility of pharmacy-provided services, consumers expected their insurance provider to cover services similar to current coverage offered for the same services within the physician’s office setting. Most consumers were unwilling to pay more than their current copay for preventive and primary care services. Willingness to pay out-of-pocket was impacted by current insurance coverage and income. Those on public insurance (Medicare/Medicaid) noted that if they could get the service for free or much less than at the physician’s office, they would be willing to go out of their way to obtain the service. Consumers reported a higher willingness to pay for urgent services. Paying out-of-pocket for a quick, basic service, such as a vaccination or blood pressure check, is acceptable.

“I would expect all of those services to be covered by my insurance unless I have already met the limit on how often a service can be covered in a year, such as preventive annual exams.”

—Woman, large city

Pharmacists’ Perspectives

The pharmacists included in the analysis had a mean of 14 years of experience (SD, 8 years), and included an equal number of men and women. Eleven had doctorate of pharmacy (PharmD) degrees, and 9 had baccalaureates (bachelor’s degrees). Six respondents worked in rural settings, 2 in a small town, 7 in a suburb, and 5 in a large city. Pharmacists practiced in a mix of community settings, with 6 in independent pharmacies, 2 in a mass merchandise outlet, 2 in a national chain, 5 in a regional chain, and 5 in a supermarket. In terms of professional titles, 2 were pharmacists-in-charge, 11 were pharmacy managers, 1 was a pharmacy supervisor, and 6 were staff pharmacists.

In general, the pharmacists who were interviewed were cautiously optimistic about the opportunities associated with expanding healthcare offerings in the community-based pharmacy of the future. They indicated that they were aware of the benefits associated with expanded healthcare offerings in terms of societal, public health, and their own job satisfaction. They also saw the benefits of ease of access to quality healthcare and cost-efficiency, and universally recognize the importance of patient interactions. Pharmacists recognize the ability to generate additional revenue.

“To a strong degree, we currently act in this way. Patients come to us all the time wanting recommendations, and asking us to ‘look at this.’”

—Pharmacist, baccalaureate, local chain

“I think the value would be increased revenues for pharmacies, [and] more jobs in pharmacy departments.”

—Pharmacist, baccalaureate, supermarket

The pharmacists we interviewed were divided on the types of expanded healthcare offerings to place in a pharmacy. Some saw a logical extension of the current expanded offerings, such as vaccinations. However, receptivity to provide examinations and diagnostic services was limited.

“I would like to see the pharmacist actually treat patients instead of just making referrals, but of course the time it [would] take to do this needs to be considered, and provisions need to be made accordingly, I think. Patients would benefit from this service, saving them time and allowing diseases to be treated almost immediately.”

—PharmD, national chain

The barriers to offering examination and diagnostic services in a community setting cited by pharmacists are training, resource limitations, privacy considerations, enhancing interprofessional communication lines, and potential for legal liability. They also noted that staffing would be an important barrier to the delivery of expanded healthcare services, and expressed concern that physicians and other healthcare providers may not be receptive to expanded pharmacy healthcare services.

“It’s reasonable given our knowledge and training. However, it is not reasonable given the amount of time we currently have in the pharmacy to perform our duties.”

—PharmD, national chain

Pharmacists reported that they believed that the benefits of convenience and cost would outweigh the public’s concerns about their expertise. They also believe that patients would be receptive to receiving primary care services from a pharmacist. Their rationale is their belief that the patient will have a higher trust in pharmacists versus other healthcare professionals.

“I think that initially people would be hesitant for some services, but eventually would recognize convenience and professionalism of the pharmacy, and see it as a great option for management of certain conditions.”

—PharmD, supermarket

Payers’ Perspectives

Respondents had a mean number of 18 years of experience (SD, 3 years), and were predominantly men (7). In terms of payer organizations, the majority (6) were employed by commercial payers with Medicare, 1 by a commercial payer only, and 1 by a Medicare payer only. In terms of job titles, the majority (6) were medical directors, 1 was a pharmacy operations manager, and 1 was vice president of operations.

Payers reported being open with respect to where healthcare services are needed. They universally recognized the potential for cost-efficiency advantages, based on their experience with vaccinations and convenience clinics to date.

“Personally, I think it’s a great thing. It’s cheaper. It’s easier. Patients do not have to get a bus down to the doctor’s office. I am [a] big fan.”

Payers shared some concerns about the ability of pharmacists and pharmacies to take on more services, especially as it relates to financial risk.

“They don’t have time, and their reimbursement level might not justify that involvement.”

Payers reported looking to federal and state statutes and regulations for guidance on the legality of new services offered by healthcare providers. If a particular state’s pharmacy board approves the delivery of a particular healthcare service through pharmacies, then the pharmacy and the payer focus on negotiating a reimbursement framework. The payer organization typically does not make a determination about whether they will or will not support pharmacies that deliver that service.

“If a state decides a pharmacist can do something—that is not our job to decide. We’ll treat them the same as we would a physician’s practice. We would determine whether pharmacists deliver care, then what kind of fee schedule we want to go with.”

Discussion

The goals of the Triple Aim of the Institute of Healthcare Improvement are better care for individuals, improved health for the population, and lower cost per capita.11 These aims have become the foundation of efforts to improve healthcare delivery in the United States. To this end, a team-based primary care workforce has been called into action.12-16 Setting aside arguments for enhanced quality of care by leveraging teams, one of the primary reasons for team-based care provision is the projected shortage of 12,500 to 31,100 primary care physicians by 2025.17 The emergence of convenience clinics has developed, in part, to address the Triple Aim at a local point of care, and use of nonphysician providers because of the emerging physician shortage.

This study was carried out to understand how consumers, pharmacists, and payers qualitatively view the demand for these clinics in the US primary healthcare marketplace. Patient feedback suggested that community pharmacies—with and without convenience clinics are viewed, in a traditional sense, as a place for medication delivery. Pharmacists understand that evolution of the traditional pharmacy store must occur; they see the need, but remain cautious in embracing this evolution. Finally, payers are less focused on the place of delivery—or even who the deliverer is—but emphasize quality of care.

There has been a rapid building of convenience clinics across the United States, but growth of these clinics seems to be plateauing. This is despite more than 20 million visits in the past decade. Our results support these findings, because patient responses show that they see these clinics as part of the medication delivery system—especially when placed in pharmacies—and not as places where they routinely seek care. The reason for these responses may be a lack of a consistent public healthcare message about convenience, quality of care, and lower cost offered at these clinics. The underserved are not being messaged, and such clinics are not being located in areas where they can be frequented by this patient population. Thereby, the underserved are not using these clinics, but continue to use higher cost “habitual” places of care, including emergency departments.5 A second issue may be the presentation of the clinic as a place of care that is open, comfortable, and with a modern appearance. A third reason has been restrictive state regulations on nurse practitioners’ scopes of practice.5 Finally, reimbursement for services provided by nurse practitioners is below that offered for the same care by physicians.5,18 Although payers are very open to convenience clinics and the opportunities they provide for quality care, systems of reimbursement need to be examined to even the playing field.5,18

Pharmacists have been called to actively participate in the new era of primary care. Our study results would suggest that the profession remain divided into 2 camps: the traditional drug dispensing and medication advice mode, versus a patient-centric system of pharmacy/pharmacist-delivered comprehensive care services. Despite many examples of quality care being delivered by community pharmacists,19-21 the profession self-advocates barriers that may limit the expansion of pharmacists into primary care. This is especially troublesome because pharmacists are needed most in rural, underserved areas. One solution, as stated by some of our pharmacist respondents, is to share resources via a team-based approach to care.

This study is limited in that it is a qualitative exploration of the perceived demand for community pharmacist prescribing. We are in the process of fielding compressive surveys of patients and pharmacists across the United States, to model the demand for enhanced primary healthcare services to be delivered in the community pharmacy setting. A key focus of this research will be to determine to what extent our qualitative observations from this study are quantitatively validated, and model the actual demand for pharmacist prescribing in general, and across rural versus urban settings, ethnic minority populations, and socioeconomically disadvantaged communities, and whether this practice will enhance access to quality healthcare.

Conclusion

This qualitative study of consumers, pharmacists, and payers highlights opportunities and gaps between current and future provision of primary care through convenience clinics. Consumers and pharmacists both acknowledge the possibility of expanded primary care offerings through these clinics, and potential benefits in terms of improved access and convenience, but are split between those who hold the more traditional dispenser–advisor model, and those who favor a more progressive primary care provider model. Payers do not appear to be an obstacle to these services, as long as the services offered are within the scope of practice of the provider, and regulated at the state level. However, reimbursement systems that favor these clinics are in need of evolution. In addition, there appears to be a need for greater public promotion of these clinics in order for these clinics to continue becoming an innovation model that is here to stay.

Acknowledgment

Research funded by Skaggs Institute for Research, Salt Lake City, UT.

References

Cohen RA, Martinez ME. Health insurance coverage: early release of estimates from the National Health Interview Survey, 2014. www.cdc.gov/nchs/data/nhis/earlyrelease/insur201506.pdf. Published June 2015. Accessed January 21, 2016.